Sir

We were heartened that the BMJ has featured cardiac rhythm management in its recent editorial (1) but were disappointed that the article put a spin on hard won progress and attention that was ill informed and misleading.

The growth in attention that has turned towards cardiac rhythm problems has been in progress for at least the last 10 years and predated any drug company interest in the problem. The Arrhythmia Alliance is an excellent example where patients and health care professionals have collaborated to bring attention to a problem that is much more abstract than the blockage of an artery that can be opened with a balloon. A marker of the struggle in drawing attention away from “plumbing” to “electrics” is that even now, when both doctors and the general public see a collapse and resuscitation on television, they will still call it a heart attack and the deputy editor of the BMJ “cannot be sure what cardiac rhythm” might prompt cardiac massage and repeated defibrillation (it is ventricular fibrillation).

Over 10 years ago the outrage expressed by patients and the public that the significant illness and death associated with cardiac arrhythmia was completely ignored by the “national service framework for coronary artery disease” led to the addition of a single arrhythmia chapter(2). Other important drivers for increasing attention have been an improved understanding of how existing therapies offer benefit (warfarin is just as safe as aspirin but much more effective at preventing AF related stroke, especially in the elderly (3)) and the development of new interventions like catheter ablation which can transform people’s lives. The new drugs like dronedarone have been very disappointing in their efficacy and are rarely prescribed by heart rhythm specialists and the new anticoagulants have really had little impact on our practice or prescribing behaviour yet. The increase in mentions in the BMJ have been a reflection of how far behind we were and how much things have improved.

What is the real future for arrhythmia management? The universally consistent feedback we have from patients (through charities like the Atrial Fibrillation Association we can actually canvass patients’ opinion and be guided by it) is that they are frustrated by the length of time it takes for them to see healthcare professional with a special interest in rhythm problems. This can be a nurse, GP or cardiologist, but their interest in rhythm problems (rather than a background of management of coronary disease or other cardiac problems) makes all the difference to the help and advice they get. We hope that this will be the standard of care in the next decade that patients will come to expect.

The editor mentions that “Fabrice Muamba has become the new patron saint of arrhythmias with his doctors not far behind”. I would challenge the editor to find a single reference in the press naming or quoting the heart rhythm specialist actually looking after Mr Muamba and I would suspect that he is confusing opinions given in the press by cardiologists, with the care that has actually been delivered by the heart rhythm specialist. We would give the same advice to the editors that we give to our patients, seek referral to a heart rhythm specialist (again this could be a nurse, GP or cardiologist) before giving your opinions, albeit very entertaining and provocative ones.

1) Delamothe T. From rags to riches: the atrial fibrillation story. BMJ. 2012;344:e3871.
2) Department of Health. National Service Frameworks. Coronary Heart Disease. London:Department of Health, 2000.
3) Mant J, Hobbs FD, Fletcher K, Roalfe A, Fitzmaurice D, Lip GY, Murray E; BAFTA investigators; Midland Research Practices Network (MidReC). Warfarin versus aspirin for stroke prevention in an elderly community population with atrial fibrillation (the Birmingham Atrial Fibrillation Treatment of the Aged Study, BAFTA): a randomised controlled trial. Lancet. 2007;370:493-503

Competing interests: None declared